A meta-ethnography of the factors that shape link workers’ experiences of social prescribing

Background Social prescribing is gaining traction internationally. It is an approach which seeks to address non-medical and health-related social needs through taking a holistic person-centred and community-based approach. This involves connecting people with and supporting them to access groups and organisations within their local communities. It is hoped that social prescribing might improve health inequities and reduce reliance on healthcare services. In the UK, social prescribing link workers have become core parts of primary care teams. Despite growing literature on the implementation of social prescribing, to date there has been no synthesis that develops a theoretical understanding of the factors that shape link workers’ experiences of their role. Methods We undertook a meta-ethnographic evidence synthesis of qualitative literature to develop a novel conceptual framework that explains how link workers experience their roles. We identified studies using a systematic search of key databases, Google alerts, and through scanning reference lists of included studies. We followed the eMERGe guidance when conducting and reporting this meta-ethnography. Results Our synthesis included 21 studies and developed a “line of argument” or overarching conceptual framework which highlighted inherent and interacting tensions present at each of the levels that social prescribing operates. These tensions may arise from a mismatch between the policy logic of social prescribing and the material and structural reality, shaped by social, political, and economic forces, into which it is being implemented. Conclusions The tensions highlighted in our review shape link workers’ experiences of their role. They may call into question the sustainability of social prescribing and the link worker role as currently implemented, as well as their ability to deliver desired outcomes such as reducing health inequities or healthcare service utilisation. Greater consideration should be given to how the link worker role is defined, deployed, and trained. Furthermore, thought should be given to ensuring that the infrastructure into which social prescribing is being implemented is sufficient to meet needs. Should social prescribing seek to improve outcomes for those experiencing social and economic disadvantage, it may be necessary for social prescribing models to allow for more intensive and longer-term modes of support. Supplementary Information The online version contains supplementary material available at 10.1186/s12916-024-03478-w.


Background
Social prescribing is an approach to health and wellbeing that seeks to acknowledge and address some of the effects of the social determinants of health (1).While various de nitions, models, and implementation approaches of social prescribing exist internationally, it involves "a deliberate, individualised process connecting individuals to non-clinical services and activities, typically provided by the voluntary and community sectors" (2) (p.2).In practice it entails working with service users (patients), and then signposting and supporting them to connect with organisations and groups within their local communities.Examples may include referrals to gyms and other lifestyle support groups and services, arts, and cultural activities (3), green spaces (4), as well as services that can offer support with housing, nances and welfare advice (5).Social prescribing is gaining traction internationally, with at least 25 countries around the world introducing it as of 2023 (1).
Social prescribing is frequently framed as a way of addressing health inequities by responding to the social determinants of health (6), with policy makers stating that it is "effective at targeting the causes of health inequalities" (7).Social prescribing is presented as a "community-centred" approach to health and wellbeing, which "seeks to draw on and strengthen community capacity to take collective action that will in turn lead to changes in health or the social determinants of health" (8) (p.19).It has also been described as an "asset-based" approach, which aims to recognise and focus on a community's strengths (rather than its de cits) as a foundation for creating social change (8).
In England, social prescribing is now a key part of the NHS Long-Term Plan and Personalised Care Agenda (9), with hopes that it will reduce the reliance on NHS primary care services (10) as well as reduce clinician workload (5).Its delivery is supported through the introduction of social prescribing link workers, who have been brought on as new non-clinical members of the NHS primary care workforce (11).Link workers support service users in identifying issues affecting their health and wellbeing, accessing community-based support.A key aspect of the link worker role is to undertake activities aligned with the "asset-based" approach.This involves working collaboratively with partners from across the health and care system to both identify and ll gaps in community services provision and encourage community mobilisation (12,13).
The ways in which link workers operate locally can vary considerably (14), with some providing intensive open-ended support, while others operate within clearly de ned boundaries providing "light touch" (15) support which may be limited to signposting (6).Currently, in England, link workers can be employed directly through funds made available to Primary Care Networks (PCNs) or contracted through third-sector organisations (14).The NHS Long Term Workforce Plan, which lays out a cost-effective approach to meeting current and future healthcare demands, commits to increasing the number of link workers employed from 3000 in September 2022 to 9000 by 2036/37 (16).
The literature on social prescribing and link workers is growing rapidly, both across the UK and internationally.Many of these studies are qualitative explorations of the experiences, implementation, and effects of social prescribing in different settings.A consistent theme from current research has been the need to develop a re ned theoretical understanding of the processes that shape the ways in which link workers undertake their role across a range of settings (17,18).However, to date there has been no synthesis that attempts to develop a theoretical understanding of the factors that shape link workers' experiences of their role.

Aim and rationale
The aim of this review was to synthesise existing qualitative research on factors shaping link workers' experiences of their role and the ways in which the role is being implemented.Our synthesis sought to develop a novel conceptual framework which explains how social prescribing is being enacted and experienced by frontline social prescribing staff.The review aimed to answer the following research questions: 1. What are the experiences and perceptions of link workers carrying out social prescribing?2. What factors in uence the ways in which link workers work with patients?

Study design
As the aim of this review was to develop a novel theoretical understanding of the factors that shape link workers' experiences of social prescribing, we employed a meta-ethnographic approach to evidence synthesis to integrate qualitative literature on the link worker role.Meta-ethnography (19) is a theory generating and interpretive methodology for the synthesis of qualitative evidence (20).The approach is interpretive, rather than aggregative, and involves systematically comparing and translating data from qualitative studies such as participant quotes ( rst order constructs) and concepts/themes developed by authors of the primary study (second order constructs) (21).This process then enables the identi cation and development of new overarching theories and conceptual models (sometimes referred to as third order constructs) (20,22) through reinterpretation (re-analysis) of published ndings (23).Conducting a meta-ethnography involves seven stages: getting started, deciding what is relevant to the initial interest, reading the studies, determining how the studies are related, translating the studies into one another, synthesising the translations, and expressing the synthesis.The protocol for the review was registered on PROSPERO [CRD42021264595].We followed the eMERGe guidance when conducting and reporting this meta-ethnography (20).

Identi cation of Studies: deciding what is relevant to the initial
We conducted a systematic search of key electronic databases covering a mixture of health and social sciences literature to identify published qualitative studies containing data about factors that shape link workers' experiences of their role and its implementation.We searched nine databases in August 2021 with the health of an information specialist (NR).The search strategy consisted of title/abstract keywords and subject headings describing the link worker role, primary care and qualitative research.The search terms recognised the fact that link workers are sometimes referred to by other titles such as social prescriber or community connector (14).No date, language or publication type limits were applied to the search.Full search strategies are available on request.In addition, we searched OpenGrey for grey literature such as policy reports.As the literature on social prescribing is growing rapidly, we set up a Google Scholar alert with the term "social prescribing" to keep abreast of newly published papers.This continued until the point of nalising our analysis in November 2023.We also scanned the reference lists of included papers to identify other potentially eligible studies which may have been missed by our searches.The inclusion criteria for studies in our review can be found in Table 1.

Table 1
Criteria for publications to be included in the review

Inclusion Exclusion
• Qualitative studies (that used a qualitative approach to data collection and analysis) • Mixed methods studies where qualitative components could be distinguished from the quantitative ones • Studies with perspectives from link workers employed through primary care as well as other agencies • Studies with perspectives from services users, primary care staff, or voluntary and community sector staff which discussed factors relevant to link workers' experiences of their roles • Written in English The rst author (AT) conducted the initial screening of the retrieved references by title and abstract to exclude irrelevant studies, and a sample (20%) was screened by a second reviewer to ensure that inclusion criteria were being applied consistently.Disagreements were resolved through discussion.Remaining texts were read in full and assessed for their relevance.All screening was managed using Rayyan, a systematic review management platform.The bibliography of each included paper was scanned to identify further eligible papers.The same process and criteria were also applied to studies identi ed by the Google Scholar alerts.

Quality appraisal
There is considerable debate on whether or not qualitative research should be subject to critical appraisal; some argue that doing so sti es the interpretive and creative aspects of qualitative research, reducing it to a list of overly prescriptive technical procedures (24), or that the checklists do not appreciate the heterogeneity of approaches to qualitative research (25).Noblit and Hare (19) did not advocate for formal appraisal of studies as part of meta-ethnography as they argued that study quality would become apparent by how much it contributed to the synthesis (19,26).However, critical appraisal has been performed in meta-ethnographies to examine the overall quality of included papers and to identify gaps in the reporting (27,28).With this in mind we undertook a critical appraisal of the studies included in the review using the Critical Appraisal Skills Programme (CASP) Qualitative Studies Checklist (29), but did not exclude studies based on their scoring.

Synthesis
Each stage of our synthesis was an iterative process during which the research team met regularly to discuss emerging ideas.These were also discussed with a patient and public involvement group and a stakeholder group which included social prescribing link workers, policy makers and social prescribing managers.

Reading the studies
All included publications were read and re-read by the lead author (AT) to identify and become familiar with its key concepts and to determine how studies related to one another by comparing their aims, focus, characteristics, theoretical approach, and ndings.We extracted themes from each of the papers (second order constructs) using a table in which these were noted along with illustrative data ( rst order constructs).We also noted additional ideas that arose while reading the papers to help inform the development of third order constructs.
Determining how the studies are related During this stage, we considered the relationships between the key concepts (second order constructs) we extracted from the papers.This involved looking across the studies for similar or recurring concepts.We grouped them into initial categories which we labelled using terminology that adequately described all the relevant concepts they contained.These were then juxtaposed and compared against each other to explore the possible relationships between the key concepts from the original studies.We drew initial "conceptual maps" (see Additional File 1) to aid the exploration of how these initial categories might relate to each other.

Translating studies into one another
"Translating" is central to meta-ethnography.It describes the idea that each author is using their own "interpretive language" and therefore a comparison of conceptual terms across studies is needed.This comparison involves the reading and understanding of the meaning of the original authors' interpretations, but no further conceptual development but no further conceptual development (28).Second order constructs from the included studies were compared systematically to identify the range of concepts and whether their meanings were similar or contradictory.This involved noting and summarising each second order construct and its de nition in an Excel table and mapping the presence of each construct across each of the included studies.During this process we re-examined the initial categories developed in the previous stage and reorganised them based on the emerging translations.

Synthesising Translations
We undertook a reciprocal synthesis where the different studies included were viewed as a whole and from which we were then able to build a line of argument or overarching model (30) which explains the new emerging storyline of the synthesis (31).We revisited the categories developed in previous stages through further discussion which facilitated additional interpretation and allowed us to develop key overarching concepts (third order constructs)see Table 3.These nal third order constructs were then linked through additional discussion and analysis to develop a "line-of-argument synthesis", which aims to provide a further interpretation that puts any similarities and differences across studies into a new interpretive context (21).This allowed us to produce an overarching conceptual framework of the experiences of link workers carrying out social prescribing.

Findings
The searches of online databases yielded 2,545 records.We screened each record's title and abstract for relevance, after which we read 75 records at full text level.From the database search, 15 papers were included in the review, 5 additional papers were identi ed through the Google Scholar alerts, and a further 1 paper was identi ed through scanning the bibliographies of included papers (see Fig. 1).In total we included 21 studies published between 2017 and 2023, reporting the results of 17 different studies (5 publications included report the ndings from one larger project) (Table 2).The 21 studies included in the meta-ethnography (Table 2) were published between 2017 and 2023, and included over 531 participants, and a range of social prescribing initiatives.Sample sizes varied between 8 and > 31 participants (in one of the studies it was unclear how many participants took part (33).Seven studies included perspectives exclusively from link workers or social prescribing managers; seven included the perspectives of link workers in addition to other staff (e.g.GPs or voluntary and community sector staff) involved in the delivery of social prescribing; two included the perspectives of link workers and patients; two included a mixture of perspectives from link workers, other staff and patients; two discussed service user perspectives only; and one study included perspectives from members of the public.Seventeen of the studies were based in England, and the remaining four in Scotland.While our inclusion criteria did allow for studies on social prescribing outside of the UK, none of the publications found through the searches included international publications on social prescribing that met the rest of the inclusion criteria.Eight studies explicitly stated that they were based in socioeconomically disadvantaged areas.
Most of the studies employed interview techniques (either in person or online), some were focus groups, while others used a mixture of techniques such as interviews, focus groups, participant observation, and ethnographic eldwork.None of the grey literature identi ed through the searches provided enough detail on data collection or analysis to be included in the review.

Critical appraisal
Following the CASP Checklist (53), most of the studies included clear and relevant research aims, used appropriate methodologies and research designs, and clearly stated their ndings (see Additional File 2).However, some did not explicitly discuss re exivity, or ethical considerations beyond indicating that the studies had received approval from research ethics committees.

Synthesis
Through the synthesis we developed a "line of argument", whereby a narrative is produced based around third order constructs (19).Our analysis highlights inherent tensions present at each of the levels that social prescribing operates at, arising from a mismatch between the policy logic of the intervention and the material and structural reality into which social prescribing is being implemented.These tensions shape link workers' experiences of their role and could jeopardise social prescribing's sustainability.
The narrative is presented in the proceeding sections, with the third order constructs organised under four headings that represent each of the levels at which social prescribing operates -the link worker level, the organisational level, the wider system level, and the patient level -and highlights the tensions present at each level.
Throughout the next section, authors' interpretations (from included papers) are included in quotation marks, whilst direct quotations from study participants in the included studies are presented in italics with quotation marks.Table 3 presents the third order constructs and how they t into our overall line of argument, and which papers made contributions to each constru The link worker level Our analysis revealed tensions relating to the ways in which the link worker role itself has been implemented into the health and care system.These tensions relate to role de nition, professional identity, relational working, and the reliance on individual link worker characteristics as drivers of success.Each of these tensions has implications for link workers' workloads, and the ways in which their roles are understood and accepted by others working in healthcare.These factors may act as stressors on the link worker role, threating retention and in turn risking the ability for social prescribing to deliver desired outcomes.
Role de nition as a double-edged sword Link workers have been introduced into the health and care system as a new role, often with a exible remit and without a clear job description (35,36,47).
On the one hand, this exibility could allow link workers to tailor the way they worked to t with the population and area they serve, ultimately helping them to provide person-centred care (38, 44).However, this same lack of clear role de nition could also cause role stress through workload overload and complexity.The exible nature of the link worker role meant it had been operationalised in different ways across different organisations (35), with "their job scope and remit being poorly de ned from the outset" and their role being "not well understood by external referrers" (47) (p.3).This could lead to unrealistic expectations or confusion around what is achievable through social prescribing (50) and to the referral of patients with complex needs that exceeded the remit of the link worker role (35,38,39).
Link workers were sometimes used to " ll gaps", which is an identi ed risk of having unclear professional identities in newer professions (44).In the studies, parameters of the link worker role were frequently exceeded due to concerns that nobody would support patients otherwise, because "no other professions would deviate from their role boundaries" (44) (p.5).Furthermore, a lack of understanding of referral criteria could lead to link workers feeling that social prescribing was being "used as a dumping ground for di cult patients" (36) (p.6).The lling of gaps was particularly pertinent in the context of overstretched and underfunded statutory and mental health services.In these contexts, link workers often ended up taking on more clinical risk (40,44) or providing more specialist support such as acting as unquali ed social or advocacy workers (40), due to long waiting lists or lack of availability for more specialised services.Not having onward referral options may also limit link workers' ability to set boundaries with service users (49,51).
The quasi-professional status of the link worker role Link workers have been introduced into the health and care system as a new "professional" role, but without the formal training and registration that would afford them professional status (35) and identity to give them the con dence needed to deal with complex cases they encounter in their work (44,47).
Coupled with the lack of understanding or ambivalence about the role from other primary care professionals, link workers sometimes felt that they were "treated as outsiders going apparently unrecognised by practice staff" (46) and sometimes found it di cult to become integrated and visible in primary care due to "entrenched professional hierarchies" (37) (37) .
Formal training is considered essential for the building of professional identity and status (44), however, across the studies there was variation in the training link workers had received.While formal training could increase link worker con dence in performing their role (51), some link workers reported that it was often minimal, inconsistent and non-standardised (44).Some needed to draw on skills and training they received in previous roles (44); those taking on more senior responsibilities felt like they did not have enough training for this (32).In other contexts link workers re ected that the training they had received was overly theoretical and lacked practical elements to prepare them for dealing with the range, severity, and complexity of issues they encountered (47,51); or with speci c health conditions (48).It was also acknowledged that formal training available to link workers is improving and that this may suggest that social prescribing is moving towards integration into mainstream practice (44).Furthermore, opportunities for career progression within the role were often limited, which could affect role retention (Beardmore, 2020;Fixsen et al., 2021).
The absence of a shared and commonly understood role and professional identity and pathway could threaten professional resilience and ful lment (44) and the retention of link workers (32,44).However, it was noted that professionalising the role by bringing in formal quali cations and registration may have consequences that hinder the successful delivery of social prescribing (44).On the one hand, formal professionalisation and registration may increase the legitimacy of the role, as well as improve equitable access to social prescribing and consistency for patients through greater standardisation (44).Yet it was noted that making the link worker role a registered profession may make the role more restricted and remove individuality and the exibility currently available in social prescribing, which is key to person-centred care (38,44).It may also present a barrier to connecting with service users who may nd it easier to relate to someone who is not a "professional" and "more like them" (44).Finally, creating a "barrier to entry" through requiring registration and speci c training may impact recruitment to the role which was already di cult (44).
Balancing tensions in the relational nature of link working Social prescribing hinges on link workers establishing and nurturing relationships between individuals and organisations in a way that builds trust and fosters collaboration (35-38, 43, 45, 50-52), Relationships with link workers were sometimes likened to friendships by patients, and contrasted to interactions they were used to having with healthcare professionals -often depicted as rushed and impersonal (52).Link workers were described as a "companion" with whom patients could share their stories; these close relationships were necessary for the success of social prescribing (52).This relational nature of social prescribing work was described as being "a bit of a balancing act" between being a "friend but not a friend" (51) (p.996),where it was also vital to maintain boundaries in a way that did not foster patient dependency (38) and protected link workers' time and headspace (50).A key strategy for setting boundaries with service users involved referrals into other agencies, although as described later, local community infrastructure may not always be readily available to permit this to happen (51).
Being able to get to know patients, to explore and understand their individual contexts, and "empowering" (36)(p.6)them to make decisions for their health and wellbeing could be a "particularly satisfying" aspect of the link worker role (36) (p.6).A link worker in the study by Beardmore, 2019, noted that "I just love working with people.It's quite a privilege to be part of someone's journey" (32) (p.44)The author notes that this satisfaction was despite the potentially negative impact of the lower salary of the link worker role due to the relational nature of the link worker role and the satisfaction secured from working with people (32).However, in the study by Moore et al. 2023, link workers felt that they were not being remunerated enough for the workload and risk they often found themselves taking on.
Link workers' ability to form relationships with other healthcare professionals and community organisations was also key to the success of social prescribing services (33,36,38,49,51).They were uniquely placed to act as a bridge between different stakeholders due to their understanding of both primary care as well as the voluntary and community sector (49).This networking aspect of the role required the link worker and social prescribing service to be fully embedded into the practice and that when it was, it could lead to the whole practice team having links with community organisations (33).However, in other cases it could be challenging to transition from individual relationships between staff to more enduring collaborations with organisations, irrespective of the individuals involved (49).Staff continuity is a concern for the longevity of these collaborative relationships, which can be compromised if link workers leave their role due to poor job satisfaction.

A reliance on individual characteristics as drivers of success
As described above, we identi ed no singular, clear de nition or remit of the link worker role, or speci c previous experience or training required to undertake it.However, it was apparent that the skills, experience, and personal characteristics that link workers possessed were often the driving force behind social prescribing programmes, meaning the role should not be undertaken by "just anyone" (41) (p.4).
Previous professional backgrounds often in uenced how link workers approached their role and the amount of con dence they had in its execution (40).For example, link workers who previously worked in mental health professions or had mental health training felt more con dent and able to make decisions (39).
Empathy, being non-judgemental and supportive, compassionate, having listening skills and being able to put people at ease, were all considered essential traits for link workers (34,36,41,49,51), and necessary for building the trust required to encourage behaviour change and non-directive goal-setting (51).
Knowledge of the local area was considered key for promoting collaborative working between primary care and community organisations (35,49).
Furthermore, being proactive and tailoring the service to the needs of the local community was also essential to the success of social prescribing (40).
A reliance on the characteristics of individual link workers as drivers for success may pose a threat to the sustainability of social prescribing schemes given the role stresses described above which may threaten the retention of link workers in their role.

The Organisational Level
The organisational realities into which link workers and social prescribing were implemented shaped experiences of the role.The extent to which primary care organisations bought into social prescribing, were able to provide support and space for link workers, as well as funding models and targets could in uence the experience of link workers in social prescribing programmes.

Organisational buy-in to social prescribing
Across studies, the extent to which organisations within which link workers were based bought into or understood the service could have a considerable impact on how link workers experienced their role."Social prescribing champions", staff with an in-depth understanding of the remit of the role and who worked to embed social prescribing into practices, could help facilitate link worker access to practice meetings, training sessions, and increase visibility of the social prescribing service in the practice (39,46).Strong collective leadership -where responsibility for social prescribing was shared between GPs, link workers, and practice managers, could work to integrate social prescribing into the practice and enabled link workers to be proactive and strategic with the community networking aspect of their role (33).In cases where practices were not as engaged or did not fully understand what the service could offer, link workers had to take a more active role promoting the service, leaving less time to provide focused and holistic person-centred care (46, 51).Co-locating link workers in primary care, providing space for them in practices, was noted to help referrers to understand and remember the link worker role (50), as well as making the service seem trustworthy and credible to patients/service-users (35).
The pressure of targets Organisational targets and service funding models that reward high referral volume and the completion of wellbeing assessments could in uence link workers' approaches to patient care.These targets may cause a drift towards social prescribing approaches that prioritise the completion of assessment instruments at the expense of more holistic person-centred care (37,46,51).Furthermore the pressure to generate a high number of referrals could mean they accepted clients not necessarily ready to engage with social prescribing, or those with complex needs (51).

Support for link workers
To cope with high workloads, complex cases, and emotional burden, studies highlighted organisational support which could have a positive impact on link workers' experiences of their role.The support available to link workers varied across the different contexts described in the studies.It was noted that link workers in larger organisations with clear organisational structures were more likely to be part of teams where workload could be shared and had better access to support and training (32).Those working in teams with other link workers could draw on them for emotional support and re ection (47), and this could help promote a sense of success in the role (37).Well-embedded workforce support and clinical supervision was key to being able to deal with the complex cases link workers found themselves working with (39).Where organisational support for link workers was not in place, some could nd themselves feeling isolated which could lead to feelings of anxiety and decreased capacity to cope (32,39,47) The System Level A key part of the link worker role is to facilitate service users' social prescribing journeys from primary care to groups and organisations in their communities.Social prescribing programmes depend on a "thriving" local community sector (34), that provides referral options for link workers to meet patient needs (40).
A number of the studies we reviewed drew attention to the fact that the wider health and social care system, as well as the voluntary and community sectors, are overstretched and underfunded (34,35,37,39,40,46,49,51). Several papers highlighted the impact that austerity has had both on the availability of community and statutory services, and on the demand for them; this has been described as a "perfect storm" (49) (p.e493) and a "threat to the future sustainability" (40) (p.1541) of social prescribing.
A struggling wider health and social care system Link workers sometimes felt like social prescribing was being used as a way to "boost up a crippled mental health service" (32) or as a "holding pen" (38), when other services that were over capacity, with long waiting lists, referred into social prescribing (39).Fixsen et al. (35) talked about "changing demands" where they describe how the pressure from closure of various local statutory and non-statutory services was compounded by the impact of the Covid-19 pandemic, and limited onward referral options for link workers.This meant that link workers needed to provide support for people with complex and/or severe mental health concerns, as well as support for those experiencing food poverty, unemployment, or needing bene ts advice (39).

Local variation and structural poverty
Across the studies it was reported that the availability of services could vary across localities.A uent areas were sometimes described as having an "abundance of community activities" (40), while those working in areas with high levels of socioeconomic disadvantage noted that this context limited their scope for onward referral (37).Link workers made references to "structural poverty", identifying the lack of investment in the local area (37).Area level differences in service provision have implications for accessibility to services, in terms of requiring access to transport (37,39,40,51) and being able to tailor support to patient needs (48), as well as with service users' ability to engage with social prescribing due to complex life circumstances (46, 52).

Link workers as an additional resource
In the context of a system struggling from the effects of austerity, link workers were "welcomed as an extra resource" to tackle workload (Skivington et al., 2018 p. e491), or to deal with "the social" (42).However, as described in earlier sections, link workers' poorly de ned role made them vulnerable to " lling gaps" (44).
The lack of onward referral options or other appropriate sources of support described above may mean that link workers end up taking a more involved approach to patient care than originally anticipated (40).This may involve taking on more risk than they have training for, due to having to deal with complex cases when there is no other support available (44).There may also be a risk that patients develop "dependency" on their link worker in the absence of other support (50).Having appropriate onward referral options was highlighted as key to helping to avoid patient dependency on the link worker (50), and to improving link workers' ability to cope with high numbers of social prescribing referrals (51).Providing longer-term and more intensive support may be counter to the original logic of social prescribing which seeks to signpost people away from primary care to appropriate community or statutory services (5).
The Service-User Level Social prescribing and the personalised care agenda (9) emphasise providing service users with "choice and control", and assume that they will be motivated and empowered to make changes that will bene t their health and wellbeing.However, across the reviewed studies, there was evidence to suggest that those experiencing precarious life circumstances may not be able to engage with social prescribing to the same extent as service users from more a uent backgrounds, highlighting that those in the most disadvantaged positions may be least likely to bene t.This calls into question social prescribing's goal to help improve health equity.While more intensive and involved approaches to social prescribing may bene t disadvantaged groups, they require additional time, training, and support for link workers, and may not immediately deliver on social prescribing's goal to reduce patient attendance in primary care.
Challenges to the dominant discourses of "choice" and "empowerment" Gri th et al. ( 2023) observed how link workers' narratives about their role were often ideological and con icted and drew on different and multiple social prescribing discourses.They mention Mol's work (54) and highlight the logics of "choice" and "care" which appeared to be dominant in the social prescribing discourses among link workers, as well as in the policy logic of social prescribing.The "logic of choice" gives prominence to individual choice and control over services and support received.In the context of social prescribing, this means that service users have a range of options to choose from, and they are encouraged to take an active role in deciding which services and activities they would like to participate in.The onus is on individual service users to become "empowered", through support provided by the link worker, to take control of their health, health behaviours, and personal situation.The "logic of care", on the other hand, emphasises relational and holistic support, and focuses on building strong relationships with service users and tailoring support accordingly.
A dominant narrative among primary care staff was that poor health is caused by poor individual lifestyle choices, and that the role of social prescribing is to build the con dence of service users and to empower them make better decisions in relation to their health and wellbeing (42,44), and to encourage "selfaccountability" (38).In some cases it was suggested that service users need to be able to self-refer to social prescribing as it signalled empowerment and autonomy.Conversely, it is argued that practitioner-led referral risks cultivating dependency (50) which could be considered a "threat to success" for social prescribing (38).
However, a number of studies drew attention to the various material and social circumstances that may shape the lives of service users and impact on their ability to engage with social prescribing.Experiences of social prescribing can be described as "classed", and the focus on empowerment and motivation may mean that service users from more a uent backgrounds are able to engage with the intervention and invest in their long-term health (46).Social determinants of health shape the parameters within which individual service users might be able to exercise choice and autonomy, as illustrated in this quotation from a participant in the study by (42): "life's not great, they've got very little in the way of money now and they're being squeezed and sanctioned 'til they're blue in the face.They haven't got a job, they probably have to go and get a job, if they do ... it'll be like a zero-hour contract below the living wage ... and so, to try and do that little bit extra about trying to live a more healthy lifestyle can just seem a bit pointless."Furthermore, local variation and lack of local investment, and structural poverty described in the previous section may limit the "choice" of onward referrals for service users, further problematising the notions of choice and empowerment which are at the heart of some social prescribing discourses.
Temporal and material requirements for person-centred care Despite the discourses emphasising personal empowerment, link workers do engage in approaches which can be interpreted as more aligned with the "logic of care".Link workers often support service users with basic needs such as housing, homelessness, unemployment, nancial support (40,45,46,49,51).
They may also take on more intensive approaches to link working by offering longer-term support (52), conducting home visits (43,52), accompanying service users to activities or groups in the community (37,46,52), helping users from socioeconomically disadvantaged areas to navigate and access community services (51), and providing advocacy (37).These more involved and longer-term approaches to social prescribing could be key in supporting individuals with multiple long-term conditions and experiences of socioeconomic deprivation (51).
However, these more involved approaches may require more time, more training for link workers, and may cause high levels of stress and emotional burden.
Furthermore, as described in previous sections, the material and structural reality into which social prescribing has been placed may not be best suited to supporting such approaches to social prescribing.Such approaches may also not immediately deliver on social prescribing's goal to reduce patient attendance in primary care as patients may require multiple visits over longer periods of time before feeling "empowered".

Line of Argument
Our analysis has highlighted inherent tensions present at each of the levels that social prescribing operates, which may arise from a mismatch between the policy logic around this initiative and the material and structural reality into which social prescribing is being implemented.These tensions may shape link workers' experiences of their role and call into question the sustainability of social prescribing and the link worker role as currently implemented.A visual summary of the key components of our line of argument can be seen in Fig. 2.

FIGURE 2 HERE
Visual summary of key components in the line of argument developed through this synthesis of qualitative literature.It depicts the different tensions at each of the levels at which social prescribing operates and which in turn shape link workers' experiences of carrying out their role.
At the link worker level, the way in which the role itself has been delineated and implemented may threaten the ability of social prescribing to deliver its intended outcomes.Link workers have been introduced into the health and care system as if they were a "professional" role, but without the formal training and registration that would afford them professional status.In its current form, the link worker role is not strictly de ned or boundaried.On the one hand, this exibility in the role may allow link workers to tailor the way they work to t with the population and area they serve, ultimately helping them to provide person-centred care.On the other hand, it can cause role stress through workload overload and complexity, as well as confusion/ambivalence among other members of staff about what social prescribing is and what the link worker role can offer, in turn contributing to inappropriate referrals.In the context of an overstretched system, link workers may end up lling gaps and "holding" (55) service users they cannot move on into other more appropriate services.
Enjoyment and ful lment in the role appear to come from the fact that connecting with services users and supporting them on their journeys feels rewarding.
The role stress that link workers may experience coupled with low wages, may pose a threat to link worker retention.Given that much of the success of social prescribing seems to rely on individual link worker characteristics (such as being well-connected, knowledgeable about the local area, and having the skills needed to connect and build trusting relationships with service users), the role stress link workers experience and associated implications for link worker retention, may have implications for the success of social prescribing programmes.
The organisational contexts into which link workers and social prescribing are being implemented into can vary and signi cantly and in uence link workers experiences and the ways in which social prescribing is embedded into practice.Organizational buy-in, including support from leadership and champions who advocate for link workers and help to integrate them and the service into practices appears to be essential.Furthermore, co-locating link workers in primary care settings may enhance their visibility and credibility.Organisational targets and funding models can shape link workers' approaches, sometimes leading to a focus on quantity of referrals rather than person-centred approaches.Support from organisations, including clear structures, teamwork, and access to training and supervision, are essential for link workers to manage their workload and address the emotional aspects of their roles effectively.
Social prescribing and the link worker role are about moving service users out of primary care, and into other sources of support which may be "more appropriate".The logic of the intervention relies on the presence and accessibility of onward referral options -community organisations and services, health and social care services, and statutory services.Yet, as discussed in several studies in this synthesis, decades of austerity have had an impact on both the availability of community and statutory services, as well as the demands for them through the impact it has had on individual livelihoods.
Social prescribing and the personalised care agenda (9), emphasise providing service users with "choice and control", and assume that they will be motivated and empowered to make changes that will bene t their health and wellbeing.However, across the studies we reviewed, there was evidence to suggest that those experiencing precarious life circumstances may not be able to engage with the intervention to the same extent as service users from more a uent backgrounds.The pervasiveness of the discourses of choice and control may shift link workers' away from more intensive person-centred approaches which may be more likely to bene t those experiencing di cult life circumstances and health inequities.

Discussion
The aim of this meta-ethnographic synthesis was to develop a novel conceptual framework to understand the factors that shape link workers' experiences and explains how social prescribing is experienced by frontline social prescribing staff.Our synthesis of 21 qualitative studies found that the lived reality of being a link worker appears to be shaped by tensions present at each of the levels at which social prescribing operates.
One of the dominant discourses, or policy logics, promotes social prescribing as a means of tackling health inequities through overcoming the social determinants of health and addressing failures of the health system to do so (6).A number of the studies included in the synthesis discuss the impact that the long lasting effects of austerity have had both on the system level infrastructure into which social prescribing and link workers have been introduced as well as on people's livelihoods (37,42,46,49,52).The "structural antecedents" (5) required for social prescribing to succeed have been shaped by political and economic forces which have seen cuts and disinvestment in voluntary and community as well as statutory organisations (56).These cuts have tended to disproportionately affect disadvantaged areas, where the need for services is usually greater (56, 57) and have worked to widen health inequalities (56).The idea that social prescribing might mitigate the impact of austerity on healthcare by linking service users with community resources and encouraging collaborative working between organisations may therefore be questioned.The lived experience of link workers, as depicted in papers included in this review, highlights how the state of the wider health and care system both impacts their workloads and their role stress due to the fact that they may nd themselves "holding" (55) service-users who they cannot connect onwards due to relevant services or support either not being present or having limited capacity (37,58).
Furthermore, the current shortage of physical space within GP surgeries (59) may mean that they are not able to provide link workers with physical space in practices which may play a key role in supporting the success of social prescribing schemes (50).The cuts in funding to public services may also have an impact on an organisation's ability to adopt new healthcare innovations, such as social prescribing (60).
Other authors have highlighted the pervasiveness of neoliberal rhetoric present within social prescribing discourses (42,61).Neoliberalism is a political and economic ideology that emphasises market-based values such as individual choice, competitiveness, economic liberalisation, privatisation, and pro t maximisation.It is said to lead to policies that promote individual choice and responsibility, and commodi cation, which can have negative impacts on health and health equity (62).Austerity measures, such as cutting social spending, align with the neoliberal focus on minimising government involvement and reducing public services in order to promote economic growth.This can result in policies that prioritise budgetary constraints over social welfare (62).The focus on individuality and empowerment place the onus on maintaining health on individuals and communities (37).
Social prescribing policy emphasises community-centred ways of working and asset-based community development (63) These approaches focus on leveraging the strengths, skills and resources within a community, rather than focusing on its de cits; empowering communities to work collaboratively to address social issues in a way that fosters sustainable and positive change (64).However, critics argue that these approaches can shift responsibility and resources away from the state and onto communities and may inadvertently contribute to inequality and justify cuts to social programmes (64).
The focus on individual choice and empowerment in social prescribing has been called "fantastical" (42), individualising health inequalities and targeting individual behaviours as the main solution, rather than addressing the fundamental causes of inequalities and ignoring the socio-political determinants of health (65).As shown in this review, the material and social circumstances of people's lives can in uence their ability to engage in social prescribing; in the context of austerity, where community services and infrastructure may be limited, "choice" and "control" can become misnomers.While those experiencing disadvantage may bene t from social prescribing, this may require a more involved and long-term approach from link workers that supersedes the 6-12 sessions over a three month period typically expected for social prescribing (66).Evaluative work by the authors has identi ed that a lack of cohesion between what is expected in terms of patient turnover and what is needed to support people with challenging life circumstances can become a considerable source of tension for link workers, affecting their job satisfaction and retention (67) .
Our review highlighted the role stress link workers experience through lack of a clear role de nition and professional status.Role stress can occur when individuals face con icting or incompatible expectations within a role they occupy, or when roles are unclear or poorly understood (68).This strain arises from the challenges of balancing multiple and sometimes contradictory demands and expectations associated with the role.While role exibility appeared to be a requirement for the delivery of person-centred and responsive care, the struggling infrastructure into which the link worker role has been established means it is at risk of being used to ll-gaps.While a signi cant policy rationale for social prescribing is its potential to meet unmet needs and contribute to service development in local communities (5), gap-lling may expose link workers to more risk and complexity than they are prepared, trained, or compensated for, risking link worker retention (44).In other contexts, it has been cautioned that "gap-lling" may undermine a profession's attempt at establishing itself and being understood by others (69).This may also make it di cult to feel valued or respected by colleagues due to the lack of appreciation of the role's unique contribution to healthcare (69).
While the infrastructure that social prescribing and link workers have been implemented into may pose a number of challenges that threaten the sustainability of social prescribing, it is important to recognise that there are examples of social prescribing schemes that have thrived (70,71) and that it can have positive outcomes in people's lives (52).Future research could explore the ways in which link workers navigate the challenges of structural and material realities they work in to deliver positive outcomes for service-users.

Strengths, limitations, and re exivity
This review is the rst to synthesise published qualitative data of social prescribing link workers' experiences of carrying out their role in a way that develops a novel theoretical understanding.A key strength of this review lies in its meta-ethnographic approach.This led to the development of a "line of argument synthesis" which allowed us to move beyond the ndings of individual studies to create a theory that is more than the sum of the parts included in the synthesis (72).
As with other qualitative syntheses, our review relied on the interpretations of the original study authors as well as their selection and presentation of study participant quotes (27).We include participant quotes throughout our synthesis to help ensure it was grounded in participant experiences.Meta-ethnography was originally developed for synthesising meaning across ethnographies, which traditionally provide thick descriptions of the phenomena they are studying in order to contribute to a broader theoretical understanding.This thick description and focus on meaning, supports the development of third order interpretations within a meta-ethnographic synthesis.As Atkins et al. (27) also found, qualitative research in health service research and public health is often more descriptive and applied and focused on providing evaluations and recommendations for policy and practice (73).This meant that third order interpretations may be more dependent on themes identi ed in studies than interpretations (27).
The review team comprised a range of multidisciplinary expertise from social science, clinical practice, and health service, policy, and social prescribing research.This different expertise was helpful in developing the focus of the synthesis, and through the analysis process of translating and interpreting meaning across the different studies.The lead author (AT) has research interests in health inequities, the social determinants of health, and the social, economic, and political forces that drive them, which may have had an impact on how study ndings were read and interpreted.However, emerging ndings were discussed with a lay patient and public involvement group, as well as with a range of key social prescribing stakeholders in order to sense check interpretations as they were developing (74).

Conclusion and implications
This review has shown that link workers experience challenges in their role due to the structural realities (at a practice and broader level) within which the role has been developed and implemented, and these are also shaped by political and social forces.Our review highlights a need for greater consideration of how the link worker role is de ned, deployed, and trained, as well the need to ensure that the infrastructure it is being implemented into is su cient to meet needs.
Social prescribing models may need to allow for more intensive and longer-term modes of delivery to support those experiencing social and economic disadvantage.This may require moving away from outcomes-based approaches to funding and evaluation (37).Further considerations ought to be given to ensuring that the community infrastructure is available and able to receive social prescribing referrals.A failure to acknowledge the wider reality of people and communities means that social prescribing risks being a neoliberal solution to problems neoliberalism has caused.Therefore, it may not be able to deliver its intended outcomes.Social prescribing should not be considered a substitute for broader social policy changes needed to address health inequities and ensure the equitable distribution of funding to areas and populations of greatest need.

Declarations
Ethics approval and consent to participate: As this was a synthesis of published literature, ethical approval for this study was not required.

Consent
Not applicable as this is drawing on previously published data that we appropriately reference in the paper.
It could also lead to confusion/ambivalence among other members of staff about what social prescribing is and what the link worker role could offer, in turn contributing to inappropriate referrals.

Figures
Figures

Figure 1 Figure
Figure 1 Figure legend not available with this version.

Table 3
Formation of third order constructs from second order constructs in each included paper.Publications with * were based on the same larger study.The "X" in argument each paper contributed to.

Table 2 Table of
study characteristics.The * beside 6 of the publications indicate that they report ndings from the same larger project.